人工全膝關節置換術中止血帶應用對圍手術期失血量及近期療效的影響研究_《中國修復重建外科雜志》

作者：

杜哲 , 劉培來 , 張元凱 , 李德強 , 李明

山東大學齊魯醫院骨科（濟南，250012）;

關鍵詞：

人工全膝關節置換術止血帶圍手術期失血量并發癥

DOI：

10.7507/1002-1892.20130288

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目的探討初次人工全膝關節置換術（total knee arthroplasty，TKA）中，止血帶應用對圍手術期失血量及術后近期療效的影響。方法回顧分析2010年9月－2011年12月接受初次TKA治療且符合選擇標準的94例94膝骨關節炎患者臨床資料，其中51例術中使用止血帶（A組），43例未使用止血帶（B組）。兩組患者性別、年齡、側別、體重指數、術前血紅蛋白（hemoglobin，Hb）水平、患肢膝上10 cm周徑、關節活動度、疼痛視覺模擬評分（VAS）、美國特種外科醫院（HSS）評分、美國西部Ontario與McMaster大學骨關節炎指數評分（WOMAC）比較，差異均無統計學意義（P gt; 0.05），具有可比性。記錄并比較兩組患者術后紅細胞壓積（hematocrit，Hct）、Hb、隱性失血量、顯性失血量及理論總失血量，以及兩組手術時間、住院時間、患肢膝上10 cm周徑增加率、VAS評分、關節活動度、HSS評分、WOMAC評分。結果術后A組4例（7.84%）、B組1例（2.33%）輸血，術后輸血率比較差異無統計學意義（χ2=1.410，P=0.235）。術后2 d，兩組Hb及Hct比較，差異均無統計學意義（P gt; 0.05）。A組術中顯性失血量少于B組，隱性失血量多于B組，差異有統計學意義（P lt; 0.05）；但兩組理論總失血量比較差異無統計學意義（t=0.662，P=0.510）。A、B組手術時間、住院時間及術后3 d VAS評分比較，差異均無統計學意義（P gt; 0.05）。患者術后切口均Ⅰ期愈合，無相關并發癥發生。術后3 d A組膝上10 cm周徑增加率高于B組（t=9.435，P=0.000），7 d時差異無統計學意義（t=0.462，P=0.645）；術后3、5 d，B組關節活動度優于A組（P lt; 0.05），7 d時兩組比較差異無統計學意義（t= —1.279，P=0.204）。患者均獲隨訪，隨訪時間12～18個月，平均14.3個月。兩組術后1年HSS評分差異無統計學意義（t=0.952，P=0.344），WOMAC評分比較差異有統計學意義（t= —2.488，P=0.015）。X線片復查示，假體位置良好，無松動及下沉，無骨溶解。結論TKA術中應用止血帶增加隱性失血量，與未使用止血帶相比在降低輸血率上無明顯優勢，建議對于有血栓栓塞高風險患者減少止血帶使用時間及壓力。

引用本文： 杜哲,劉培來,張元凱,李德強,李明. 人工全膝關節置換術中止血帶應用對圍手術期失血量及近期療效的影響研究. 中國修復重建外科雜志, 2013, 27(11): 1318-1323. doi: 10.7507/1002-1892.20130288 復制

1.	Abdel-Salam A, Eyres KS. Effects of tourniquet during total knee arthroplasty. A prospective randomised study. J Bone Joint Surg (Br), 1995, 77(2): 250-253.
2.	Klenerman L. Is a tourniquet really necessary for total knee replacement. J Bone Joint Surg (Br), 1995, 77(2): 174-175.
3.	Nadler SB, Hidalgo JH, Bloch T. Prediction of blood volume in normal human adults. Surgery, 1962, 57(2): 224-232.
4.	Jarolem KL, Scott DF, Jaffe WL, et al. A comparison of blood loss and transfusion requirements in total knee arthroplasty with and without arterial tourniquet. Am J Orthop (Belle Mead NJ), 1995, 24(12): 906-909.
5.	Matziolis D, Perka C, Hube R, et al. Influence of tourniquet ischemia on perioperative blood loss after total knee arthroplasty. Orthopade, 2011, 40(2): 178-182.
6.	Tarwala R, Dorr LD, Gilbert PK, et al. Tourniquet use during cementation only during total knee arthroplasty: a randomized trial. Clin Orthop Relat Res, 2013. [Epub ahead of print].
7.	Ishii Y, Matsuda Y. Effect of tourniquet pressure on perioperative blood loss associated with cementless total knee arthroplasty: a prospective, randomized study. J Arthroplasty, 2005, 20(3): 325-330.
8.	Sehat KR, Evans R, Newman JH. Hidden blood loss following hip and knee arthroplasty. Correct management of blood loss should take hidden loss into account. J Bone Joint Surg (Br), 2004, 86(4): 561-565.
9.	高玉鐳, 李佩佳, 田敏, 等. 人工全膝關節置換術隱性失血的發生機制及影響因素分析. 中國矯形外科雜志, 2012, 20(3): 209-212.
10.	Authier B. Reactive hyperemia monitored on rat muscle using perfluorocarbons and 19F NMR. Magn Reson Med, 1988, 8(1): 80-83.
11.	Klenerman L, Chakrabarti R, Mackie I, et al. Changes in haemostatic system after application of a tourniquet. Lancet, 1977, 1(8019): 970-972.
12.	Mylod AG Jr, France MP, Muser DE, et al. Perioperative blood loss associated with total knee arthroplasty. A comparison of procedures performed with and without cementing. J Bone Joint Surg (Am), 1990, 72(7): 1010-1012.
13.	Aglietti P, Baldini A, Vena LM, et al. Effect of tourniquet use on activation of coagulation in total knee replacement. Clin Orthop Relat Res, 2000, (371): 169-177.
14.	Fahmy NR, Patel DG. Hemostatic changes and postoperative deep-vein thrombosis associated with use of a pneumatic tourniquet. J Bone Joint Surg (Am), 1981, 63(3): 461-465.
15.	Nakahara M, Sakahashi H. Effect of application of a tourniquet on bleeding factors in dogs. J Bone Joint Surg (Am), 1967, 49(7): 1345-1351.
16.	Smith TO, Hing CB. Is a tourniquet beneficial in total knee replacement surgery? A meta-analysis and systematic review. Knee, 2010, 17(2): 141-147.
17.	Fukuda A, Hasegawa M, Kato K, et al. Effect of tourniquet application on deep vein thrombosis after total knee arthroplasty. Arch Orthop Trauma Surg, 2007, 127(8): 671-675.
18.	Tai TW, Lin CJ, Jou IM. Tourniquet use in total knee arthroplasty: a meta-analysis. Knee Surg Sports Traumatol Arthrosc, 2011, 19(7): 1121-1130.
19.	高福強, 李子劍, 張克, 等. 初次全膝關節置換術后肢體腫脹的影響因素研究. 中國矯形外科雜志, 2011, 19(9): 724-727.
20.	Rosencher N, Kerkkamp HE, Macheras G, et al. Orthopedic Surgery Transfusion Hemoglobin European Overview (OSTHEO) study: blood management in elective knee and hip arthroplasty in Europe. Transfusion, 2003, 43(4): 459-469.
21.	McManus KT, deBethizy JD,Garteiz DA, et al. A new quantitative thermospray LC-MS method for nicotine and its metabolites in biological fluids. J Chromatogr Sci, 1990, 28(10): 510-516.
22.	Norton MR, Eyres KS. Irrigation and suction technique to ensure reliable cement penetration for total knee arthroplasty. J Arthroplasty, 2000, 15(4): 468-474.

1. Abdel-Salam A, Eyres KS. Effects of tourniquet during total knee arthroplasty. A prospective randomised study. J Bone Joint Surg (Br), 1995, 77(2): 250-253.
2. Klenerman L. Is a tourniquet really necessary for total knee replacement. J Bone Joint Surg (Br), 1995, 77(2): 174-175.
3. Nadler SB, Hidalgo JH, Bloch T. Prediction of blood volume in normal human adults. Surgery, 1962, 57(2): 224-232.
4. Jarolem KL, Scott DF, Jaffe WL, et al. A comparison of blood loss and transfusion requirements in total knee arthroplasty with and without arterial tourniquet. Am J Orthop (Belle Mead NJ), 1995, 24(12): 906-909.
5. Matziolis D, Perka C, Hube R, et al. Influence of tourniquet ischemia on perioperative blood loss after total knee arthroplasty. Orthopade, 2011, 40(2): 178-182.
6. Tarwala R, Dorr LD, Gilbert PK, et al. Tourniquet use during cementation only during total knee arthroplasty: a randomized trial. Clin Orthop Relat Res, 2013. [Epub ahead of print].
7. Ishii Y, Matsuda Y. Effect of tourniquet pressure on perioperative blood loss associated with cementless total knee arthroplasty: a prospective, randomized study. J Arthroplasty, 2005, 20(3): 325-330.
8. Sehat KR, Evans R, Newman JH. Hidden blood loss following hip and knee arthroplasty. Correct management of blood loss should take hidden loss into account. J Bone Joint Surg (Br), 2004, 86(4): 561-565.
9. 高玉鐳, 李佩佳, 田敏, 等. 人工全膝關節置換術隱性失血的發生機制及影響因素分析. 中國矯形外科雜志, 2012, 20(3): 209-212.
10. Authier B. Reactive hyperemia monitored on rat muscle using perfluorocarbons and 19F NMR. Magn Reson Med, 1988, 8(1): 80-83.
11. Klenerman L, Chakrabarti R, Mackie I, et al. Changes in haemostatic system after application of a tourniquet. Lancet, 1977, 1(8019): 970-972.
12. Mylod AG Jr, France MP, Muser DE, et al. Perioperative blood loss associated with total knee arthroplasty. A comparison of procedures performed with and without cementing. J Bone Joint Surg (Am), 1990, 72(7): 1010-1012.
13. Aglietti P, Baldini A, Vena LM, et al. Effect of tourniquet use on activation of coagulation in total knee replacement. Clin Orthop Relat Res, 2000, (371): 169-177.
14. Fahmy NR, Patel DG. Hemostatic changes and postoperative deep-vein thrombosis associated with use of a pneumatic tourniquet. J Bone Joint Surg (Am), 1981, 63(3): 461-465.
15. Nakahara M, Sakahashi H. Effect of application of a tourniquet on bleeding factors in dogs. J Bone Joint Surg (Am), 1967, 49(7): 1345-1351.
16. Smith TO, Hing CB. Is a tourniquet beneficial in total knee replacement surgery? A meta-analysis and systematic review. Knee, 2010, 17(2): 141-147.
17. Fukuda A, Hasegawa M, Kato K, et al. Effect of tourniquet application on deep vein thrombosis after total knee arthroplasty. Arch Orthop Trauma Surg, 2007, 127(8): 671-675.
18. Tai TW, Lin CJ, Jou IM. Tourniquet use in total knee arthroplasty: a meta-analysis. Knee Surg Sports Traumatol Arthrosc, 2011, 19(7): 1121-1130.
19. 高福強, 李子劍, 張克, 等. 初次全膝關節置換術后肢體腫脹的影響因素研究. 中國矯形外科雜志, 2011, 19(9): 724-727.
20. Rosencher N, Kerkkamp HE, Macheras G, et al. Orthopedic Surgery Transfusion Hemoglobin European Overview (OSTHEO) study: blood management in elective knee and hip arthroplasty in Europe. Transfusion, 2003, 43(4): 459-469.
21. McManus KT, deBethizy JD,Garteiz DA, et al. A new quantitative thermospray LC-MS method for nicotine and its metabolites in biological fluids. J Chromatogr Sci, 1990, 28(10): 510-516.
22. Norton MR, Eyres KS. Irrigation and suction technique to ensure reliable cement penetration for total knee arthroplasty. J Arthroplasty, 2000, 15(4): 468-474.

《中國修復重建外科雜志》

人工全膝關節置換術中止血帶應用對圍手術期失血量及近期療效的影響研究

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《中國修復重建外科雜志》

人工全膝關節置換術中止血帶應用對圍手術期失血量及近期療效的影響研究

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